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Background A majority of surgical patients are prescribed opioids for pain management. Many patients have pre-existing chronic pain managed with opioids and/or opioid use disorders (OUDs), which can complicate perioperative management. Patients who use opioids prior to surgery are at increased risk of developing OUD after surgery. To date, no studies have examined the prevalence of opioid screening and electronic medical record (EMR) documentation prior to surgery. Materials and methods A 40-item survey was administered to 268 patients at their first postoperative care visit at a single tertiary academic center from October 2017 to July 2018. A chart review of a random sample of 100 patients was performed to determine provider opioid screening prevalence in the presurgical setting. Log-binomial models were used to calculate prevalence ratios (PRs) to determine the provider role (surgeon, advanced practice clinicians [APC], surgical trainee) association with opioid screening documentation. Exploratory qualitative interviews were conducted with surgical providers to identify barriers to screening and screening documentation. Results Only 7% of patients were screened preoperatively for opioid use. A total of 38% of patients self-reported that they had used opioids in the past year. Of that group, only 3% had screening by a surgical provider prior to surgery documented in their EMR. Provider role was not associated with likelihood of opioid screening (surgeon versus trainee, PR = 1.2, 95% CI 0.2-8.5) (surgeons versus APCs, PR = 1.05, 95% CI 0.17-8.53). EMRs were discordant with patient survey results for patients with no ICD-10 codes for opioid use. The most common perceived barriers to preoperative screening were insufficient clinic time; logistics of who should screen/not required as part of their clinical workflow; not perceiving screening as a priority; and lack of expertise in the area of chronic opioid use and OUD. Conclusions Preoperative screening for opioid use is uncommon, and EMRs are often discordant with patient self-reported use. Efforts to increase preoperative screening will need to address barriers screening practices and increasing health system support by incorporating screening into the clinical workflow and adding it to documentation templates.

Advances in cancer care have led to improved survival, which, coupled with demographic trends, have contributed to rapid growth in the number of patients needing cancer care services. However, with increasing caseload, care complexity, and administrative burden, the current workforce is ill equipped to meet these burgeoning new demands. These trends have contributed to clinician burnout, compounding a widening workforce shortage. Moreover, family caregivers, who have unique knowledge of patient preferences, symptoms, and goals of care, are infrequently appreciated and supported as integral members of the oncology “careforce.” A crisis is looming, which will hinder access to timely, high-quality cancer care if left unchecked. Stemming from the proceedings of a 2019 workshop convened by the National Cancer Policy Forum of the National Academies of Sciences, Engineering, and Medicine, this commentary characterizes the factors contributing to an increasingly strained oncology careforce and presents multilevel strategies to improve its efficiency, effectiveness, and resilience. Together, these will enable today’s oncology careforce to provide high-quality care to more patients while improving the patient, caregiver, and clinician experience.

ObjectivesGlobal, COVID-driven restrictions around face-to-face interviews for healthcare student selection have forced admission staff to rapidly adopt adapted online systems before supporting evidence is available. We have developed, what we believe is, the first automated interview grounded in multiple mini-interview (MMI) methodology. This study aimed to explore test–retest reliability, acceptability and usability of the system.Design, setting and participantsMultimethod feasibility study in Physician Associate programmes from two UK and one US university during 2019–2020.Primary, secondary outcomesFeasibility measures (test–retest reliability, acceptability and usability) were assessed using intraclass correlation (ICC), descriptive statistics, thematic and content analysis.MethodsVolunteers took (T1), then repeated (T2), the automated MMI, with a 7-day interval (±2) then completed an evaluation questionnaire. Admission staff participated in focus group discussions.ResultsSixty-two students and seven admission staff participated; 34 students and 4 staff from UK and 28 students and 3 staff from US universities. Good-excellent test–retest reliability was observed at two sites (US and UK2) with T1 and T2 ICC between 0.65 and 0.81 (pConclusionThese preliminary findings suggest that the system is reliable, generating consistent scores for candidates and is acceptable to end users provided human touchpoints are maintained. Thus, there is evidence for the potential of such an automated system to augment healthcare student selection.

Objective There is a national shortage of psychiatric care providers, with approximately 1% of physician assistants (PAs) working in psychiatry. The study aimed to understand the utilization of PAs in inpatient psychiatry. Methods A qualitative study was performed utilizing semi-structured interviews focusing on PA autonomy, reimbursement, specialized certifications, training structure, and overall satisfaction with PAs in inpatient psychiatric care. Results Of the nine locations interviewed, four are currently using PAs, and five have never utilized PAs. All facilities utilizing PAs reported a decrease in physician workload with varying structures for training and billing, and required specialized certifications. Conclusion Most facilities surveyed do not utilize PAs and either preferred physicians or were unaware of the qualifications of PAs. Of the facilities utilizing PAs, there is wide variation in their utilization and reimbursement models; however, they reported a high level of satisfaction, reinforcing that PAs can provide high-quality care in inpatient psychiatric settings.

Background Patients living in rural communities and patients with a cancer diagnosis are two areas potentially overlooked in opioid prescribing clinical decision making that may relate to the amount of overprescribed opioids in the postsurgical environment.Methods A 35-item questionnaire was administered to surgeons, residents/ fellows (trainees), and advanced practice clinicians (APCs). Descriptive statistics were generated.Results Surgeons, trainees, and APCs self-reported that they give the same amount of opioids to rural patients as other patients. APCs were more likely to agree that it is easy to e-prescribe (56%) than surgeons (41%) and trainees (35%), so rural patients do not need different consideration. Surgeons (50%) and trainees (50%) agreed compared to APCs (0%) that it is easier to give more opioids so a patient does not have get refills if needed for pain. Compared to APCs (5%), 21% of surgeons and 45% of trainees acknowledged giving more opioid narcotics to patients with cancer than patients without a cancer diagnosis.Conclusions While both groups of prescribing providers reported that they gave the same amount of opioids to rural patients, they differed in their knowledge about e-prescribing and what healthcare access disparities may exist for the rural patient. No differences were reported between provider groups for cancer patients. Responses indicate an opportunity to work with providers to identify potential solutions for improving opioid prescribing practices in rural and cancer patients.

To describe trends in physician assistant (PA) specialty distribution, compare these trends with physicians, and quantify the relationship of PA specialty prevalence with both PA and physician salary.PA specialty and salary data were obtained from the 2013 American Academy of PAs' Annual Survey; physician specialty and salary data from the American Medical Association Physician Masterfile and the Medical Group Management Association. Analyses included descriptive statistics and linear regression.The proportion of PAs working in primary care decreased from 50% in 1997 to 30% in 2013. Substantial growth in PA proportions occurred in surgical and medical subspecialties. Regression models showed a higher prevalence of PAs in specialties with higher PA salary, higher physician salary, and higher physician-to-PA salary ratio (P0.05).PAs are moving toward subspecialty practice. Our study suggests that demand for PAs may be an important factor driving the trend toward specialization.

OBJECTIVE The purpose of this study was to assess for any associations between individual and social factors and late-stage melanoma in Kentucky from 1995 to 2013. METHODS The study combines three datasets: individual-level data from the Kentucky Cancer Registry, census tract-level data from the US Census, and county-level physician licensure data from the Kentucky Department for Public Health. The study population is described by all cases, early stage, and late stage. Logistic regression was used to evaluate the unadjusted associations between each covariate and early-stage and late-stage disease groups. All of the significant variables were assessed for interaction effect, and the significant interaction terms were used in the final model. Multiple logistic regression provided the final model of late-stage disease. RESULTS In this study population, a dramatic increase in melanoma incidence is seen from 1995 to 2013 with a threefold increase in the number of cases per year. Of the 10,109 cases reported, 13.6% have late-stage disease, with a mean age for all cases at 56.9 years and the majority being men. Late-stage cases are more commonly uninsured or insured with Medicaid or Medicare compared with cases with early-stage lesions. Having a spouse or partner is clearly protective from being diagnosed as having late-stage melanoma, whereas being uninsured or having Medicaid increases the odds of late-stage melanoma. CONCLUSIONS The incidence of melanoma is increasing dramatically. With no screening recommendation for the general population from the US Preventive Task Force, clinicians should focus on those at increased risk of late-stage melanoma: unmarried men who are uninsured or receiving Medicaid.